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Home My WebLink About10-05-06 ~ ~.d:I -.-J 15056U41046 REV-1500 EX (05~04) PA Department of Revenue '* Bureau of Individual Taxes , Dept. 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number Decedent's last Name Suffix Date of Birth Decedent's First Name MI (If Applicable) Ente,r Surviving Spouse's Information Below Spouse's last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FilL IN APPROPRIATE OVALS BELOW .. 1. Original Return <::::) 2. Supplement~1 Return <::::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required <::::) 4. limited Estate <::::) <::::) <::::) 4a. Future Interest Compromise (date of death after 12-12-82) <::::) 7. Decedent Maintained a living Trust (Attach Copy of Trust) <::::) 10. Spousal Poverty Credit (date of death <::::) 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Tele hone Numbdf;:; 6. Decedent Died Testate (Attach Copy' of Will) 9. Litigatio~ Proceeds Received 8. Total Number of Safe Deposit Boxes <::::) Firm Name (If Applicable) ..i.-',......-." '~~~ \J :0 -0 --I )> W -.J Correspondent's e-mail address: Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct nd complete. Declaration of prep rer other than the personal representative is based on all information of which preparer has any knowledge. TURN DATE c...,,,~~ CJ '- ~t:- HJ-- (?(ju~- A0:5Ep uJ../...L I ~ (/6~, ~ ~~ i ik. ~ I )L:- l.S t{ ..A..,..# 3 PLEASE USE ORIGINAL FORM ONLY DATE ,,'(~-.&~ Side 1 L 15056041046 15056041046 -.J -.J '15U5b042047 REV-1500 EX Decedent's Name: RECAPITULATION 1. Real estate (Schedule A). ............................................ 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) ,c::;:) Separa~e BillingRequested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non.probate Property (Schedule G) c::;:) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total ~ines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . .. .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10).. ... . . ... . . . . . ... . . ... . . . .. . ...... 11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subjectto Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116' (a)(1.2) X .Ol 16. Amount of Line 14 tiilx<ilble at lilieal rate X.O ~ i" 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X. 15 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 \ L 15056042047 ~'~ -' - . 15. 16. 17. 18. ,- 15056042047 .....J REV-1jOO EXP!lge 3 Decedent's Complete Address: DECEDENT'S NAME _ . r \ (}, 4 (6 '-t UJ C" \ ~ e-~ STREET ADDRESS \ \ ( v I G~"3 ~16-r~\l\. \e ~ l~t;ODlA '?.4 '-,6 L, S- CITY , File Number JUs", ~J uJ,($.(l W S 6<<-,\ W~(lr~~ \oS \ \'"" ~[ I? rtI.J(~ 14 ) P'1- ( 7 (j ~S" I STATE ' I ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payment~ A. Spousal Poverty Credit B. PriorPaym~nts ' C. Discount (1) _-".J '3 '13, r U 2;- ~r, D ..-..:: Total Credits ( A + B + C ) (2) ( '3 -, 3 I J 0 3. Interest/Penalty if applicable D. Interest - E. Penalty 4. Total Interest/Penalty ( D + E ) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. . Fill in ()val 'on Page 2, Line 20 to request a refund. (3) (4) (5) (SA) (5B) ..~ 5. If Line 1 + Line 3 is greater than Line 2, enter the differepce. This is t~e TAX DUE. " '2 _ . " '. . C".Q~ ~ \6b ~~ J A. Enter the interest on the tax due. f'e "" -.J'1\"'\J A-~\4 Sf"'~~ 6"1 .."c:.. ~~.. <:f\ ""3 ',",,!-1 B. Enter the total of Line 5 + SA. This is the BALANCE DUE. \ - /973,10 1/:31'3,10 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... 0 0 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 0 c. retain a reversionary interest; or.......................................................................................................................... 0 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)( 1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98)~ . 1 ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT (Vb SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER All real property owned solely or as a tenant In common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which Is Jolntly-owned with right of .urvlvorshlp must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV.1!ill3 EX + (1.97) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ---- All property jointly-owned with right of survivo~ must be disclosed on Schedule F. ITEM./' NUMBER // DESCRIPTION 1. ~y~o '/~~\~~i\.),q.\\O~qL... C(P~vY1C'~ ~",~G\c:.. :# US ~4:5 2s- 5 VALUE AT DATE OF DEATH L,\:) A8.5 ~hA~~ t7~(J,0 6 :z. "T'1 ctJ :t ~"\ fC Ii!=. (U ~ ~ \ C!> N r::j. L ~ vYl -Y'1(!) \'0 ~ "\ 0 c. \<:.. -rJ:. U S <-l ~~ t4 ~ ,-,,,? ~85 ~~B~e:5 "1'.7'~~1J 50 TOTAL (Also enter on line 2, Recapitulation) $ V%5tJ ( I~ (If more space is needed, insert additional sheets of the same size) . REV'15~ EX. (""* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT r1JU SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1S0S EX+ (6-98) .' . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~ SCHEDULE C-I CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Corporation Address State on Incorporation Date of Incorporation City 2. Federal Employer 1.0. Number 3. Type of Business State_ Zip Code Total Number of Shareholders Business Reporting Year Product/Service 4. Common $ $ Preferred Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. 0 Yes 0 No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? o Yes 0 No If yes, 0 Transfer 0 Sale Number of Shares Consideration $ Date Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....0 Yes 0 No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? . . . .. . . . . . . . . .. . . . . . . .. .. . . . . . .. . .. .. .. . . . .. . . . . .. ... 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax retums (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (9-00) " *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF FILE NUMBER 1. Name of Partnership Address Date Business Commenced Business Reporting Year City State Zip Code 2. Federal Employer 1.0. Number 3. Type of Business Product/Service 4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. B. c. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. 0 Yes 0 No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer 0 Sale Percentage transferred/sold Consideration $ Date Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedenfs death? If yes, provide a copy of the agreement. DYes 0 No 11. Was the decedenfs partnership interest sold? ....................................... 0 Yes 0 No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedenfs death? ................... 0 Yes 0 No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedenfs partnership interest. ,REV-1507,EX+(1-97) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE D MORTGAGES & NOTES RECEIVABLE f[9/ FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE OF DEATH DESCRIPTION 1. TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV_1506EX+(1-97)., , J - ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE A T DATE NUMBER DESCRIPTION OF DEATH 1. "Id."\ 6A\\J~ \:3 rr.~;;~ \~ ~ d ;;;. fJD, (1 CJ ~.~ (;) t1J ~t J3A.. u Ie. ~"" e. de:. \ u"1 ~:;, \ In ~J ~ ,cffst-f;);) 0 5~3b '?-9)~'3S.~O \1 ' ;' \ I ...-' " .l .1 I . TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) () ....,~~'''." ... COMMONWEALTH OF PENNShVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY If an asset was made joint within one year of the dececlent's date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A. B. c. JOINTLY-OWNED PROPERTY: ADDRESS FILE NUMBER RELATIONSHIP TO DECEDENT LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similll' identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed for joinUy-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. TOTAL\(Also enter on line 6, Recapitulation} $ (If more space is needed, insert additional sheets of the same size) _:"m>,,.,. '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET (IF APPLICASLEI NUMBER INTEREST 1. TOTAL (Also enter on line 7, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) . " '*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: 5Ltll \\1 ArJ DESCRIPTION f \..A N ~ \2.1'- \ He ") ,....Q.... } 1 e lII1tJ R./ ;Z /.., 1. Gt/IO.g ~/(1"'" vJ A Ic.e Q. C\J~ ::> p ~ (2."\ \(Y'\ ~ ~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant (--740"( W (1 ,\oJ \e-fL f/,/~A- k:J l1Jt~eJ Street Address {f:J~3 ~3"t\\" ~J 5tJtf LlJ..QR5T~UlIIt' City E: ~'(14, State~Zip r"/oZ6 Relationship of Claimant to Decedent ~ J'~ .4c..(<;. i-i1~'}...; / 1i 4. Probate Fees V.L J · ~6 " Cu\(\ 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. AMOUNT (:1, ~l{b ~ 'l d 5 CJ2.. ':30. C (~1 :35(')r1,C' cJ t r~l.{\() I ~f c.J () TOtAL (Also enter on line 9, Recapitulation) $ J33 ':' I L)() (If more space is needed, insert additional sheets of the same size) , REV-1512;" (12-<l3) .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including un reimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) , REV.151~ EX+ (9-00. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) . . '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV.1500 Cover Sheet ESTATE OF FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. o Will 0 Intervivos Deed of Trust 0 Other o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial factor per appropriate table ................................................. Interest table rate - 031/2% 06% 0 10% 0 Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years o Life or 0 Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding (number) ..... . . . . . . . . . . . . . . . . . . . . . Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12) o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ................................... 5. Annuity Factor (see instructions) Interest table rate - 0 3 1/2% 0 6% 0 10% 0 Variable Rate % 6. Adjustment Factor (see instructions) .................................................. 7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) REV-l6,IA EX+ (3-84) '*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE ilL II REMAINDER PREPAYMENT OR INV AStON OF TRUST PRINCIPAL FILE NUMBER I. Estate of II. (Last Namet (First Name) (Midclle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. R~maincler Prepayment: A. Election to prepay filed with the Register of Wills on (attach copy of election) B. Name(s) of life Tenant(s) Date of Birth or Annuitant(s) (Date) Age on date of election Term of years income or annuity is payable C. Assets: Complete Schedule l-l 1. Real Estate $ 2. Stocks and Bonds $ 3. Closely Held Stock/Partnership $ 4. Mortgages and Notes $ 5. Cash/Misc. Personal Property $ 6. Total from Schedule l-l $ O. Credits: Complete Schedule l-2 1. Unpaid liabilities $ 2. Unpaid Bequests $ 3. Value of Unincludable Assets $ 4. Total from Schedule l-2 $ $ III. E. Total value of trust assets (Line C-6 minus line 0-4) ;4'. F. Remainder factor (see Table I or Table II in Instruction Booklet) G. Taxable Remainder value (line E x line F) (Also enter on line 7, Recapitulation) Invasion of Corpus: A. Invasion of corpus $ (Month, Day, Year) B. Name(s) of Life Tenant(s) or Annuitant(s) Date of Birth Age on date corpus consumed Term of years income or annuity is payable C. Corpus consumed o. Remainder factor (see Table I or Table II in Instruction Booklet) E_ Taxable value of corpus consumed (Line C x Line D) (Also enter on Line 7, Recapitulation) s S $ "V.'~ EX+ ~.* INHERITANCE TAX SCHEDULE L-l COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION INHERITANCE TAX RETURN RESIDENT DECEDENT -ASSETS- FILE NUMBER I. Estate of (Last Name) (First Name) (Middle Initial) II. Item No. Description Value A. Real Estate (please describe) Total value of real estate $ (include on Section II, Line C- 1 on Schedule L) B. Stocks and Bonds (please list) Total value of stocks and bonds $ (include on Section II, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-l and/or C-2) (please list) Total value of Closely Held/Partnership $ (include on Section II, Line C-3 on Schedule L) D. Mortgages and Notes (please list) Total value of Mortgages and Notes $ (include on Section II, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) Total value of Cash/Misc. Pers. Property $ (include on Section II, Line C-5 on Schedule L) III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, attach additional 8Y2 x 11 sheets.) REV-1646 EX+ (3-84) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-2 REMAINDER PREPAYMENT ELECTION . -CREDITS- FilE NUMBER I. Estate of (Last Name) (First Name) II. Item No. Description A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L- 1 (please list) Total unpaid liabilities S (include on Section II, Line 0-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-l (please list) Total unpaid bequests S (include on Section II, Line 0-2 on Schedule L) C. Value of assets reported on Schedule L-l (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: Total unincludable assets S (include on Section II, line 0-3 on Schedule L) III. TOTAL (Also enter on Section II, Line 0-4 on Schedule L) (If more space is needed, attach additional 8% x 11 sheets.) (Middle Initial) Amount s "'~B'"," '* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE ESTATE OF Check Box 4a on Rev-1500 Cover Sheet FILE NUMBER This schedule Is appropriate only for estates of decedents dying after December 12,1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. . Indicate below the type of instrument which created the future interest and attach a copy to the tax return. D Will D Trust D Other I. Beneficiaries NAME OF AGE TO BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY 1. 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedenfs death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. D Unlimited right of withdrawal D Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest $ 2. Value of Une 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Une 13 of Cover Sheet) $ 3. Value of Une 1 passing to spouse at appropriate tax rate Check One 06%,03%,00% (also include as part of total shown on Une 15 of Cover Sheet) $ 4. Value of Une 1 Taxable at 6% Rate (also include as part of total shown on Line 16 of Cover Sheet) $ 5. Value of Une 1 Taxable at 15% Rate (also include as part of total shown on Line 17 of Cover Sheet) $ 6. Total value of Future Interest (sum of Unes 2 thru 5 must equal Line1) $ (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION SCHEDULE N SPOUSAL POVERTY CREDIT (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12/31/94) ESTATE OF I FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. PART I - CALCULATION OF GROSS ESTATE 1. Taxable Assets total from line 8 (cover sheet) ............................................ 1. 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits ................................................................ 3. 4. Joint Assets with Spouse ............................................................ 4. 5. PA Lottery Winnings ............................................................... 5. 6b. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6c. 6d. 6. SUBTOTAL (Lines 6a, b, c, d) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities .............................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9. If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II. PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income Tax Return for decedent and spouse.) Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 a. Spouse .......... . 1a. 2a. 3a. b. Decedent ......... . 1b. 2b. 3b. c. Joint ............ . 1c. 2c. 3c. d. Tax Exempt Income . . 1d. 2d. 3d. e Other Income not listed above ....... . 1e. 2e. 3e. t. Total ............ . 1f. 2f. 3f. 4. Average Joint Exemption Income Calculation 4a. Add Joint Exemption Income from above: (1 f) + (2f) + (3f) (+ 3) 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... 1. 2. Multiply by credit percentage (see instructions) ........................................... 2. 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. ............................... 3. 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the decedent's gross estate ............................................................. 4. 5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit. 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